Method for cardiogoniometry

ABSTRACT

A cardiogoniometry or vector cardiography system wherein signals directly derived from the bioelectrical field are not directly processed as orthogonal data but are instead especially orthogonalized in an analog computing network. Orthogonalization is based on a derivation electrode configuration space with sloping sagittal and frontal planes. The orthogonalized signals are processed in a cardiogoniometer and are also jointly recorded on a commercial electrocardiograph in parallel thereto. All the represented data which can be used for diagnosis purposes are referenced to a biological zero line, which differs from the electrical neutral point. The cardiogoniometer permits a vectorial real time measurement on the patient.

This invention relates to the field of cardiography, particularly vectorcardiography, and more specifically relates to a cardiogoniometryprocess involving the spatial vector representation of electricalquantities of the heart, and a cardiogoniometer for processing theseelectrical quantities and for representing the parameters derivedtherefrom for the diagnosis of heart diseases.

BACKGROUND OF THE INVENTION

The evaluation of an electrocardiogram includes the determination of themaximum vector in the electrical QRS quantity in the frontal plane andis described by such terms as "left position", "steep position", etc. Inaddition, the direction of the repolarization vector, i.e., the behaviorof the electrically detectable T-wave, is considered, particularly withrespect to the direction of the QRS-vector (concordant or discordantbehavior of the T-wave). An example is the behavior of the R and Tcomponents in the course of a myocardial infarction and the recoverytherefrom. However, these evaluations are only possible in a roughlyqualitative manner and, in addition, they are often considerablyfalsified by projection-caused errors because they are based only on theprojection of these vectors on a plane but fail to take account of thedivergence of the vectors or of components thereof perpendicular to theplane.

The following conclusions can be drawn on the basis of the ambiguity ofthe projections known from the representing geometry. All ECGderivations are projections of the true angle in space onto a plane. Itis standard practice to consider a concordant T as normal and adiscordant T as abnormal. Both can be correct, but as a result of theambiguity of the projections, both can also be incorrect. Experience hasshown that it is very difficult to evaluate a T-wave as to whether it isnormal or pathological.

Thus, it is not possible to make a conclusive evaluation without knowingthe behavior of the two associated vectors in space. It is thereforenecessary to use a three-dimensional or orthogonal derivation system toobtain more accurate information and for quantitatively determiningchanges to the maximum vectors of QRS and T.

The presently recognized method for the construction of orthogonalderivations (Paul Lichtlen, Klinische Vektor-Elektrokardiographie,published by Springer, Berlin, Heidelberg, New York) consists ofmeasuring individual local electrical voltages on the surface of athorax model, the voltages being produced by an internally introducedartificial electric dipole. Accompanied by the upstream connection of aresistance network, these voltages are combined to form threederivations which correspond to the projection of the artificialelectric dipole on the frontal, sagittal and horizontal planes of thethorax model. This takes place under the idealized assumption that theelectrical field is, as a simplification, a dipole with a fixed neutralpoint.

This constitutes the SVEC III system of Schmitt and Simonson (1955),that of Frank (1956), and that of McFee and Parungao (1961). Thereproducibility in all of the systems is good and they are recognized asbeing equivalent to each other. However, even the authors have admittedthat all three systems give precise orthogonal derivations of only amodel and the orthogonality can not be strictly obtained on humans dueto individual variations in body dimensions and individual heterogeneouselectrical conductivity characteristics in the tissues surrounding theheart. It is therefore not surprising that measurements on the same testsubject with each of the three systems can easily lead to divergingresults, with regard to vector direction (azimuth and elevation) as wellas to the vector length i.e., the magnitude (Schmitt 1956, Tuna 1980).

A further disadvantage of these three systems is the complicatedderivation technology with 14, 7 or 9 electrodes. As a result, themethod is complicated for clinical use and is also very fault-prone sothat it has not, as yet, become widely used in a routine manner inclinics.

The search for a simpler derivation system has revealed that it shouldbe theoretically possible to construct orthogonal derivations from onlyfour points on the thorax. This idea is not new and, in 1936, Schellongdeveloped a derivation system with four electrodes. Using the term"vector diagram", the employed three derivations at right angles to oneanother, namely a horizontal from two points, the infraclavicular left(point zero) and right (point one), a vertical from point zero downwardsto the thorax, approximately to point V of Wilson (referred to bySchellong as point three) and a sagittal from point zero to the dorsal(point two). He considered these three derivations as projections of thedipole and, in each case, linked two of these to form a loop which hemade visible with a Braun tube. However, this technically simple methodproved to be inaccurate and there were distortions of the loop. Duchosaland Sulzer (1949) used the same cubic system but, to avoid thesedistortions, chose the zero point (the origin of the system ofcoordinates of three axes) as far away as possible from the heart,namely in the back of the body to the rear and to the right. However,this system was also not adopted, although the coincidence with thebiophysical derivation system SVEC III of Frank and McFee was not allbad (cf. Schmitt, 1956). The lack of precision of all cubic systems isdue, inter alia, to the premise that each bipolar derivation representsthe direct projection of the dipole moment of the heart. This can not beso, because each derivation is merely a potential differencemeasurement, i.e., a non-directional or scalar quantity, whereas thedipole moment, apart from its magnitude, also has a clearly defineddirection, i.e., a vector character (Irnich, 1976).

BRIEF DESCRIPTION OF THE INVENTION

An object of the present invention is to provide a simple and reliablemethod for obtaining orthogonal projections of vector quantities.

A further object is to provide a process permitting, on the basis of thederivations in accordance with the invention, a determination of thetrue angle in space between the maximum vectors of the QRS-loop and theT-loop. The locations of the two maximum vectors of QRS and T is to bemade possible by their projections on two planes.

A further object of the invention is to provide an apparatus forperforming the method.

Briefly described, the invention includes a method for detectingelectrical, heart-related signals in the natural bioelectric field of ahuman body comprising the steps of providing four electrodeselectrically connected to an apparatus for recording and analyzingelectrical signals produced at the electrodes, positioning a first oneof the electrodes at point V4 according to Wilson, positioning a secondone of the electrodes at point V8 according to Wilson, positioning athird one of the electrodes substantially vertically upwardly withrespect to the upright body, above the first electrode at a distanceequal to the distance between the first and second electrodes multipliedby a factor having a value between 0.6 and 0.8, and positioning thefourth one of the electrodes along a line substantially perpendicular tothe line between the first and third electrodes and toward the rightbody side therefrom at a distance equal to the distance between thefirst and second electrodes multiplied by a factor having a valuebetween about 0.6 and 0.8. In another aspect, the invention includes anapparatus for processing electrical signals representative of cardiacactivity, the signals being of the type derived from the human body, thesignals being referenced to a coordinate system, comprising coordinatetransformation means for transforming the signals from one coordinatesystem to another, means for sampling the coordinate--transformedsignals, means for digitizing the sampled signals, and means forevaluating the digitized signals.

BRIEF DESCRIPTION OF THE DRAWINGS

In order that the manner in which the foregoing and other objects areattained in accordance with the invention can be understood in detail,particularly advantageous embodiments thereof will be described withreference to the accompanying drawings, which form a part of thisspecification, and wherein:

FIG. 1 is a diagram illustrating the four point electrode placement andderivation system in accordance with the invention;

FIG. 2 is a diagram illustrating a projection and the formation of a sumvector therefrom;

FIG. 3 is a diagram showing the formation of the frontal plane withthree derivations;

FIG. 4 is a quadrant diagram of the sloping sagittal plane;

FIG. 5 is a tabular presentation of heart parameters in accordance withthe invention;

FIG. 6 is a diagram showing the establishment of a statistical normalrange for T and R vector directions in cartesian coordinates;

FIG. 6' is a diagram showing the fixing of the range of T and R in polarcoordinates;

FIGS. 7A and 7B, taken together, are a schematic diagram, in block form,of an apparatus in accordance with the invention;

FIG. 8 is a segment of a typical electrocardiogram wave form;

FIG. 9 is a schematic diagram in block form, of an embodiment of acardiogoniometer in accordance with the invention;

FIG. 10 is a schematic diagram, in block form, of a portion of thevector analyzer of the apparatus of FIG. 9; and

FIG. 11 is a diagram illustrating the method in accordance with theinvention.

THEORETICAL DISCUSSION OF THE INVENTION

Before going into a detailed description of the invention itself,certain important points will be briefly reviewed. The path to thedevelopment of a new model representative of the dipole moment is openedby temporarily ignoring the individual derivations, i.e., the individualelectrical signals derived from the human body by the placement ofelectrodes thereon, and considering, as a whole, the electricalconditions in a plane formed by three derivation points. When using, inthe electrocardiogram, the concept of a closed mesh, e.g., in the formof Nehb derivations D, A and I, (W. Nehb, DasBrustwarzen-Elektrokardiogramm, "Verhandlung der Deutschen Gesellschaftfur Kreislaufforschung" vol. 12, p. 177 (1939)) when considering theelectrical conditions in a triangle formed by appropriate placement ofelectrodes (FIG. 1) a relative measure for the size of the dipole momentcan be approximately obtained from the magnitude of the deflections ofthe electrocardiograph. Naturally, large or small simultaneousdeflections will always give the sum zero, corresponding to the rules ofKirchoff's Law. However, when considering the potential differencesgiven by these three derivations as partial vectors, and when they aresummed according to the rules of vectorial addition, taking into accountthe size of the deflections and their polarity on the one hand and thederivation direction on the other, a sum vector is obtained which, inthe presently represented model, can be looked upon as a dipole momentof the heart in its entirety. Thus,

    V=D+A+I.

On the basis of this, it is possible to obtain three orthogonalprojections x, y and z from four near-heart derivation points andwithout the upstream connection of the previously required resistancenetwork. Derivations D,A and I are differences of electrical potentialas measured between two electrodes such as E2 and E4, E1 and E4, and E1and E2, as shown in FIG. 1.

Naturally, it is not possible to claim absolute accuracy for this newvector construction model. This is due to the heterogeneous conductivitycharacteristics of the tissues surrounding the heart, which varies fromindividual to individual, but which is of a constant magnitude for anindividual patient so that there is no need to correct it in the waywhich is required in previous empirical or cubic systems (Schellong,Duchosal, etc.). Due to the heterogeneity of the electrical field and,consequently the lack of knowledge of the electric flux line gradient atthe derivation points according to the invention, neither the magnitudenor the direction determination of the dipole is completely accurate,but constancy and long-term reproducibility is obtained for theindividual patient, as established by hundreds of measurements. Thisresult is greatly assisted by the simple and reliable derivation methodin accordance with the invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

FIG. 1 shows the four-point derivation system in accordance with theinvention. The tetrahedral derivation system, which is to be consideredin a spatial sense, shows the four electrode attachment points E1, E2,E3 and E4. These derivation points are connected in the following way:electrodes E1 and E2 are connected as a lower pair I, the location ofelectrode E1 corresponding to point V4 according to Wilson and is,indeed, 5ICR (intercostal space) and MCL (medioclavicular line); andpoint E2 which is sagittal to E1, and which corresponds to point V8according to Wilson. Derivation point E3 is perpendicularly above pointE1 and with a preferred spacing of 1/√2 times the distance from E1 toE2, this dimension being vertical and designated V. The horizontaldimension H defined by points E3 and E4 is arranged horizontally andextends toward the right hand side of the patient also for a distance1/√2 times the distance between E1 and E2. Reference is also made to thedorsal derivation D defined by points E2, E4, and the anteriorderivation A (E1, E4), the spacing between which is determined by thepreviously described relationships. An additional perpendicular frompoint E3 to the anterior derivation is designated z_(o). In thisrepresentation, the plane containing A and I represents the slopingsagittal x,y plane, Z and A represents the frontal y,z plane, and Z,Ithe z, x-plane. The pair of derivation points E2, E3 is an unused planeand, as a redundant pair, is not taken into consideration. This does notmean, however, that diagnostically relevant information cannot begathered from this derivation.

The two derivation points E2, E3 are relatively uncritical with respectto their positions relative to the patient's heart; in other words,manipulation deviations within certain limits during the fitting ofthese electrodes always lead to the same result. The derivation pointwith electrode E3 is located on relatively displaceable tissueperpendicularly above the heart apex electrode E1, whose position mustbe very accurately determined. This derivation point E3 is displacedrelative to the geometry employed and, consequently, the heart,particularly during position changes of the patient during themeasurement. However, this does not lead to erroneous measurements. Theelectrode 3 has limited sensitivity to displacement of the tissue or tolocation errors which can be looked upon as an advantage of themeasurement technique. The measurement is not significantly influencedby position changes of the patient. It is pointed out that distinctionsare always made between x, y, z-projections and the correspondingelectrical derivations or their signals.

The electrodes are fitted to the patients in the following way for thederivation:

1. E1 corresponding to point V4 (Wilson) equals 5 ICR and MCL;

2. E2 sagittal to E1 (corresponding to point V8, Wilson);

3. E3 perpendicularly above E1 at the distance 0.7 times the distancebetween E1 and E2;

4. E4 horizontal to the right side of the patient at a distance of 0.7times the distance between E1 and E3; and

5. The ground electrode is preferrably fitted to the patient's rightarm.

This is a preferred procedure for fitting the electrodes to the patient.However, it is pointed out that for heart diagnosis on animals, only thegeometrical electrode configuration appropriate for the particularanimal should be used for derivation, while for determining theorthogonal derivation it is merely necessary to provide the coordinatetransformation stage with adequate parameters. Thus, the invention isequally suitable for use in the heart diagnosis of animals and ofhumans.

When considering subjects with a healthy heart, the vector loop passesfrom the upper front right to the bottom front left and, after reversal,back again to the upper front right, i.e., the vector loop is to agreater or lesser extent in or parallel to a plane sloping with respectto the sagittal (according to FIG. 1, the area between the threederivation points E1, E2 and E4). ECG derivations in this plane mustconsequently react in a very sensitive manner to changes of the vectorloop and this has been confirmed on well over 2,000 ECG measurements.This plane is used for constructing two perpendicularly directedprojections, x and y and the frontal plane is used for constructing aprojection z_(o) perpendicular to the Nehb plane.

In order to obtain a right triangle as the derivation triangle, which isadvantageous for trigonometric reasons, unlike in the case of Nehb,point V7 is not chosen as the dorsal derivation point of the triangleinclined with respect to the sagittal. Instead, V8 corresponding to E2is chosen which is sagittal to point V4, corresponding to E1 (apex ofheart). Thus, a right angle is obtained over the apex: derivation A isperpendicular to derivation I according to conventional ECG terminology.In addition, derivation point V8 corresponding to E2 can be clearlydetermined and easily found. By choosing point V8 according to Wilson asa dorsal derivation point, we obtain with points E1, E2, E4 a planewhich is hereinafter called the sloping sagittal plane. The derivationdesignations D, A and I used by Nehb are maintained.

When choosing the y axis of the present orthogonal system parallel toderivation A and the x axis parallel to derivation I, derivation A cannot be assumed to be a projection of the vector on axis y and derivationI cannot be considered as a projection of the vector on axis x. In fact,for vector construction purposes, all three derivations D, A and I mustbe vectorially added in the form V=D+A+I. The thus formed summationvector is projected onto the x and y axes, as shown in FIG. 2. Thefollowing formulas are obtained after trigonometric calculations:

    X=D cos 45°-I=0.7D-I                                (1)

    Y=D sin 45°+A=0.7D+A                                (2)

An additional vector projection, which is perpendicular to these twoaxes, is required as the third axis in the orthogonal system. Thisprojection z_(o) is obtained by derivation in the frontal triangle ofpoints E1, E3 and E4, points E1 and E4 representing the frontalderivation points of the sloping sagittal triangle. Point E3 is chosenin such a way that it is equidistant from points E1 and E4 and a rightangle exists between these two lines as shown in FIG. 3. In this way, aright isosceles triangle is obtained. The following derivations apply inthis triangle: horizontal derivation H from E4 to E3, verticalderivation V from E3 to E1, and anterior derivation A from E1 to E4,this being identical to derivation A in the sloping sagittal triangle D,A, I. Using the same procedure, it is also possible to construct avector in this frontal triangle by interlinking the simultaneousdeflections of the three derivations in correct sign and axis manner forvector summation. The interest of this sum vector is its projection onthe axis z_(o) in FIG. 3. This z_(o) axis is perpendicular to A frompoint E3 and, consequently, is perpendicular to the sloping sagittalplane. As this perpendicular represents the angle bisector of the rightangle point E3, this projection z_(o) of the vector can betrigonometrically represented as (V--H) sin 45°. When this expressionhas a positive sign, this vector is below the sloping sagittal plane,whereas with a negative sign it is above the sloping sagittal plane. Inother words, the z_(o) axis is positive when directed downwardly andnegative when directed upwardly and is always perpendicular to thesloping sagittal plane, i.e., perpendicular to axes x and y. In summary,it can be stated the three orthogonal projections x, y and z are:

    x=D cos 45°-I=0.7D-I                                (1)

    y=D sin 45°+A=0.7D+A                                (2)

    z=(V-H) sin 45°=0.7 (V-H)                           (3)

The calculation of the maximum vectors of QRS, P and T and thedetermination of the solid angle φ between two of these maximum vectorsis performed in accordance with the conventional space-trigonometricprocedure. The space vectors are designated 1 and 2 and theirprojections on the x, y and z axes are designated x₁, y₁, z₁ or x₂, y₂,z₂, these quantities belonging to an orthogonal, spatial coordinatesystem.

The formula for the solid angle φ conventionally used for vectorcalculation is: ##EQU1##

The scaler product is represented by the numerator and the product ofthe absolute values of the two vectors is the denominator. The length ofvector 1 is: ##EQU2## while the length of vector 2 is ##EQU3## Themaximum vector of the depolarization is, consequently, that point of thevector loop of QRS whose sum of the quadrants of the three projectionsx, y and z is greatest, i.e.: ##EQU4## The same therefore applies forthe maximum vector of the T-loop: ##EQU5##

Apart from the angle φ, interest is also attached to the position of themaximum vectors in space of QRS and T, so that it is necessary todetermine the projections of those vectors in the sloping sagittalplane, on the one hand, and in the frontal plane, on the other. It ispointed out that, for historical reasons in electrocardiography,particularly vector cardiography, the space coordinate axes aredesignated in a mathematically non-standard manner, the x, y and z axesbeing associated with respect to the human body, the origin beinglocated approximately centrally in the torso. The up and down axis alongthe body length is the y axis, the negative y axis pointing upwardlytoward the head and the positive y axis pointing downwardly. Thehorizontal axis is the x axis, the positive x axis extending to theright and the negative x axis to the left. The z axis passestransversely through the body from front to rear and that portionextending to the front front the center is the positive z axis, therearward portion being the negative z axis. This is in accordance withconvention. Contrarily, the orthogonal system according to the inventioncorresponds to the x, y, z_(o) system shown in FIG. 1 and slopes by 45°to the sagittal.

The sloping sagittal plane, determined by axes x and y, is subdividedinto 360 degrees, the 0° line being horizontally to the rear, the 90°line being to the left and downwardly, 180° to the front, and minus 90°upwardly and to the right, as generally illustrated in FIG. 4. Theconversion of the orthogonal coordinates x and y into polar coordinatestakes place in accordance with the following formulas, the polar anglein the sloping sagittal plane being designated α.

                  TABLE I                                                         ______________________________________                                        Quadrant                                                                      ______________________________________                                                       ##STR1##        (7)                                            II                                                                                           ##STR2##        (8)                                            III                                                                                          ##STR3##        (9)                                            IV                                                                                           ##STR4##        (10)                                           ______________________________________                                    

As an example, assume x to have a value of -10 and y a value of +15.From the polarity, this vector must be in quadrant II. The value ofangle alpha is thus arc tan (15/-10)+180°=124°. This example isillustrated in the second quadrant, FIG. 4.

The same procedure is used when converting the orthogonal coordinates zand y in the frontal plane while using, as a basis, the y axis of thesloping sagittal plane such that 0° is to the lower left and 180° slopesupwardly to the right. The base in the frontal plane is consequently 45°to the body axis, i.e., the sloping sagittal and not the horizontal asin the Frank derivations. The polar angle in the frontal plane isdesignated beta. Angle beta gives the precise projection of the vectoron the frontal plane and, if beta is positive, the vector passes belowthe sloping sagittal plane. If beta is negative, it passes above thesagittal plane.

The determination of the maximum vectors of QRS, P and T on the basis ofthe derivations D, A, I and H, A, V, i.e., the use of the electricalderivations signals, is the function of the cardiogoniometer accordingto the invention. The five derivation signals D (dorsal), A (anterior),I (lower), H (horizontal) and V (vertical) are formed from the fourmeasuring points E1, E2, E3 and E4 (FIG. 1) and in accordance with theabove formulas 1, 2 and 3 converted into the three projections x, y andz. The three resulting time-dependent electrical signals form threecurved paths corresponding to the projections which are measured at timeintervals of, for example, three milliseconds. Finally, these values arestored in a memory for subsequent use. Between the T wave and thefollowing P wave of the next beat, the zero line is determined andcorresponding corrections are made. If necessary, all of these storedvalues are referenced to the established zero value. The maximum sumquadrant of x₁, y₁, and z₁ on the one hand, and x₂, y₂, and z₂ on theother is determined. On the basis of this data, the cardiogoniometerthen calculates the value of cos φ according to formula 4 and determinestherefrom arc cos φ.

Thus, almost immediately, the angle φ of a single given heartbeat ismade available. The cardiogoniometer then calculates the angles αR, αT,βR and βT on the basis of formulas 7-10 and this data, including thebase data x₁, y₁, z₁, x₂, y₂, z₂ are stored. Thus, in all, 11 parameterscan be provided for the same heartbeat while the beat interval isavailable as a 12th parameter. Alternatively, the problem of the slowlyvarying zero line can be solved with a digital or analog high-passfilter.

For the purpose of checking the cardiogoniometer in operation it ispossible, for example, to simultaneously jointly record projections x, yand z on a three-channel electrocardiograph as illustrated in FIG. 9.The signals complex calculated by the cardiogoniometer are marked on thestrips containing the curve traces. As a result, a reading is obtainedwhich corresponds or is similar to the conventional representation ofthe ECG while there is also a graphic representation of certaincalculated data or actual projections of the derivations. According to apractical embodiment of the cardiogoniometer, six measured quantities φ,αR, βR, αT, βT, as well as the beat interval, are continuously printedon a printer (FIG. 5). In this way, measurement takes place roughlyevery third heartbeat. Thus, in a short time, a series of measurementscan be performed on patients, making it possible to determinestatistical values such as the mean value and standard deviation.

As an example, the standard values are determined on a group of 100 testsubjects with healthy hearts and fulfilling the following criteria:

1. No clinical criteria indicating an organic heart disease;

2. Normal ECG in the 12 standard derivations according to the prior art;

3. Constant values for all five parameters φ, αR, αT, βT according tothe invention over an interval of 10 heartbeats, the dispersion beingless than plus or minus five degrees, which means that for eachheartbeat the depolarization and repolarizations take the same"electrical path".

The thus determined values read as follows:

                  TABLE II                                                        ______________________________________                                        φ        α R                                                                            β R   α T                                                                          β T                                  ______________________________________                                        ±   15°                                                                              89.9°                                                                         9.4°                                                                              98°                                                                       3.2°                             s     7.9°                                                                              11.6°                                                                         7.8°                                                                            10.5°                                                                       8.8°                             ______________________________________                                    

When choosing ±2 standard deviations as the standard limits, thefollowing standard values (rounded off) are obtained for subjects withhealthy hearts in the supine position:

    φ=0° to 31°

    αR=65° to 115°

    βR=+25° to -10°

    αT=75° to 120°

    βT=+20° to -15°

This group contained 56 men and 44 women, the age of the test subjectsranging between 14 and 89 years, 95.4% of the cases being statisticallycovered by plus or minus two standard deviations.

In the normal case, the maximum vectors for depolarization andrepolarization are very close together, the true angle in space φrepresenting 0° to 31° (15°±16°). With an angle smaller than 31°,pathological conditions can still exist if both the depolarization andrepolarization are disturbed. Thus, great importance is attached to thelocation of R_(max) and T_(max) with respect to the sagittal and frontalplanes. These are located in a small circle around the central axillaryline (angle alpha=90°) and slightly above or below the sloping sagittalplane (angle beta=0°). FIG. 6 graphically illustrates these points.

A divergence of the vectors from this electrical center (according toFIG. 6' and indicated by a longer vector arrow) to the front, rear, topand bottom and, finally also on the rear surface (referring to therepresentation on the spherical surface according to FIG. 6') means apathological finding. Thus, there are typical displacements of theR-vector, e.g., in the case of bundle-branch blocks LBB and/or RBB andother blocks, as well as in the case of R-losses after infarctions.Moreover, each repolarization disturbance is manifested by a divergenceof the T-vector in the opposite direction from the focus of the lesion.

In the left side position, the heart is generally rearwardly displacedby approximately 10°. Thus, with respect to the angle alpha, thestandard values are displaced 10° rearwardly to: αR=55° to 105°; αT=65°to 110°.

The hitherto widely-held idea that, in the left position, perfusionproblems to the right coronary artery (RCA) could occur was confirmedwhen using the invention in comparison with coronarograms of coronarypatients, so that in the left side position in the case of ischemia inthe region of the right coronary artery, there is a forward displacementof the T-vector (alpha T becomes larger than 110°). There is also anopening for increase in the angle φ which designates the true angle inthe space between the maximum vectors QRS and T. Thus, as a routinemeasure, a cardiogoniogram in the left position should always be takenas a small functional test of the RCA.

A more or less pronounced fluctuation of the T-vector values was foundin series measurements on patients with coronary insufficiencies in thepresence of technically perfect projections x, y and z. The standarddeviation of 10 measurements is consequently above the arbitrarily fixedvalue of 5°, probably indicating myocardial ischemia. Thecardiogoniometer and derivation process according to the invention madeit possible, for the first time, to observe this phenomenon of floatingin a patient in status anginosus shortly before the occurrence of afront wall infarction.

FIGS. 7A and 7B show in simplified form the apparatus for performing theprocess. In FIG. 7A, information obtained from the human body isprocessed in four subsequent apparatus stages 10, 20, 30 and 40 up todigitalization. The first stage 10 includes circuit means for obtainingsignals from the body and shows the derivations as represented generallyin FIG. 1. These derivations are obtained by the derivation processaccording to the invention with the aid of four thorax electrodes E1-E4and a ground electrode EM which is preferably fixed to the right arm. Ofthe six derivations which can, in principle, be obtained from thistetrahedron, three are linearly independent and, in the present example,five are used. The derivation not further identified between points E2and E3 is not used because it is considered to belong to theuninteresting projection plane or is omitted as a redundant pair. Thefive derivations used are designated H for horizontal, D for dorsal, Vfor vertical, I for lower, and A for anterior.

The electrical signals of these five derivations are fed by derivationstage 10 into the coordinate transformation stage 20 wherein the desiredprojections are carried out in an orthogonal system. This is performedby a network 22, which is preferably an analog network, although it isalso possible to directly process three linearly independent derivationsin a digitizing coordinated transformation stage 20. The projections x,y and z pass from the coordinate transformation stage 20 into a samplingstage 30 where they are sampled by sample and hold circuits 32. Amultiplexing circuit 34 converts the information from parallel intoseries and also forms part of the sampling stage 30.

The serially arranged data representing the individual projections nowpasses from sampling stage 30 into a digitizing stage 40 which, in asimplified representation, comprises an analog-to-digital converter 42.The x, y, z projections are, for example, digitized as eight bit wordsin this stage, this arrangement having proved adequate for practicalpurposes. However, for more detailed resolution of the measurements orfor discovering still unknown effects within the electrical signals, itis clearly possible to provide a 16-bit or larger word arrangement.Symbolically, the digitized projections are designated (x, y, z)_(dig).

FIG. 7B shows in highly simplified form the main part 50 of thecardiogoniometer in accordance with the invention, wherein the digitizedprojections (x, y, z)_(dig) are converted into the correspondinginformative quantities. In accordance with the previously describedexample, these are the angles φ, wherein φ is the true angle in spacebetween the QRS and T maximum vectors, together with the values αR, αT,βR and βT related to the coordinate system. The heartbeat interval isderived, for example, between two QRS flanks. The cardiogoniometer part50 as shown includes a memory 52 containing the actual heartbeat data,this memory or store being of a random access type; a memory 54containing the processing program; and a microprocessor 56 which can be,for example, a Motorola Type 6800, and which is used for this datamanagement and also is used in the present cardiogoniometer for controlof the various functions; as well as the symbolically representedswitching network 58, for example, a bus system for making availableinteresting data from a memory, e.g., memory 64 (FIG. 9), which cannaturally also be supplied in serial manner from the cardiogoniometer.Strictly speaking, the data is only obtained after conversion inperipheral devices such as, for example, a display unit, a printer, ascreen or the like, but this simplified description is only intended toshow how the electrodes attached to the patient lead to very exactdiagnostic results by signal and data processing.

FIG. 8 shows the various stages for processing of a heartbeat cycleinterval as a function of time. The typical picture of an ECG curve isshown in partial form in the period from a completely acquiredQRS-complex wave to a completely acquired QRS₊₁ complex wave. The steepQR-flank is particularly suitable for triggering functional sequences.Following QR triggering at a threshold value 1, a start is made to themeasurement of the beat interval τ as well as the subdivision ofτ=(QRS+1-QRS) into various data windows t_(QRS) ; t_(p) ; t_(T) ; t_(OV); t_(QT) ; i.e., into intervals which are to be individually stored,vital importance being attached to the time t_(OV). At this point, thebase line of the curve is measured then averaged and compared with theelectrical neutral point at zero volts (OV). This base line voltage BSis used as a correction value for all of the amplitude dependentquantities such as, for example, the indicated QRS magnitude M_(QRS) andrepresents the actual biological zero line.

FIG. 9 shows in somewhat more detail the cardiogoniometer according tothe invention. The electrical measuring values of the five derivationsD, A, I, V, and H pass through individual input amplifiers 24 to ananalog calculating network 25 which represents the essential part of thecoordinate transformation circuit 22 in which is determined theprojections x, y and z according to the given formulas and the signalsof the projection quantities are made available. These signals aresubsequently amplified in output amplifiers 26 to enable them to berecorded in a parallel-operating cardiograph or its recording instrumentand, for this purpose connecting lines 29 are provided.

The x, y, z signals are supplied through individual amplifiers 31 tosample and hold circuits 32 the sample times of which are determined bysignals provided from a control program on line 35 from control circuit53. In synchronism therewith a multiplexer 34 is controlled for samplingthe signals which are provided and this is under the control of the samecontrol network 53 through line 36. This circuit portion incorporatesthe analog signal processing, the analog signals being converted todigital data in analog-to-digital converter 42. As previously indicated,in the present embodiment an 8-bit format is used, but this can beexpanded without significant additional expenditure to a 16-bit format.The digital data processing includes an input circuit 51, a data store52, shown as a random access memory, and a control program store 54,shown as an EPROM, as well as an associated microprocessor 56. Therandom access store is used for data storage while the EPROM ispreferred for storing the control program. To have control of thecalculated value done by the microprocessor, a digital display 57interfaced by interface network 55 is used. For more flexibility as toperipheral equipment the bus 58 ca be used with, as options, a printer62, a CRT-display 63, mass memory means 64 like tapes, floppy-drivesetc. all interfaced by corresponding interface networks 61. All theseblackboxes are subsumized under a peripheral evaluation block 110. Asshown in FIG. 7B, the stored data relate to the digitized heart rhythmcurves according to FIG. 8 while the control program is represented inthe structogram of the process illustrated in FIG. 11.

A detailed description of the analog-to-digital adapter module will begiven before the structogram is described. The network in question isshown in FIG. 10 and includes the x, y and z input amplifiers 31, theoutputs of which are connected to the associated sample and holdcircuits 32. As previously indicated, the sample and hold circuits aresynchronized from input circuit 51 to the microprocessor by the controlnetwork 53 and control line 35. Apart from the x, y and z data signals,which are at the input end in analog form, the multiplexer, receiveschannel selection instructions 0 and 1 as well as a multiplexer releaseinstruction from digital input circuit 51. Furthermore, input amplifiers31 and an intermediate amplifier 38 are controlled from the same circuitas to the level of amplification, by means of corresponding signalstransmitted through line 65. The heart signals from multiplexer 34 whichare to be digitized are intermediately amplified in amplifier 38 anddelivered to the ADC 42. This converter is additionally connectedthrough a separate line for status indication purposes to input circuit51 in addition to the data bus. The input circuit 51 starts the ADCconversion by means of a "convert" signal on a separate line. In theconventional manner, the input circuit 51 is connected to themicrocomputer by means of three bus systems, the data bus, the addressbus, and the control bus.

Finally, FIG. 11 shows a Jackson Structogram in simplified form. JacksonStructograms are read from top to bottom and from left to right.Examining this structogram from the left in the drawing, there is in afirst stage a learning phase which represents the adaptation of theequipment to the patient and the establishment of parameters for theamplification, sampling intervals and beat intervals result from thisphase. For this purpose, three to six cycles of the type shown in FIG. 8are used. From the beat intervals, the time measurement between twoheartbeats is obtained, as well as the patient-specific adaptation ofthe various data windows shown in FIG. 8. This followed by dataacquisition from which are obtained trigger points, the heartbeatintervals, and the offset correction. The heartbeat signals arecontinuously sampled, for example, in three millisecond intervals. Thevalues of a heartbeat cycle are stored and evaluated only after thetrigger point has been detected. This trigger point is determined byexceeding a predetermined steepness of the QR flank. Trigger pointsearches and heartbeat interval determinations are accomplished on arepetitive basis. Every third heartbeat can easily be determined at thedata conversion rate of the present embodiment. Every heartbeat can bedetermined if the necessary additional expenditure for faster circuitryis made.

In the preliminary development stage, the processing of these signalsrelates to the calculation of the maximum vectors R and T, thecalculation of the quantities αR, αT, βR, βT, etc. as well as the dataconversion and preparation. The calculated quantities are then used forevaluation purposes in so-called "on-line" readings, i.e., readings ofmeasured values are presented on a real-time basis for diagnosis duringthe measurement on the patient, often called the bedside method. Theseinclude the measuring data readout on a digital display, the readoutthereof and of further data on a printer for recording and filingpurposes, as well as the readout on a screen in the form of a graph.Then, in so-called "off-line" evaluations, i.e., away from the patient,stored signals from memory 52 are made ready for further dataprocessing, such as statistical evaluation and the like which,transferred to large data files, can be further evaluated with somewhatmore complicated programs in larger computers.

It is not possible with prior art electrocardiography to completelydetermine the electrical processes of the heart because such devicesonly involve measurements in one plane. Such analysis is only possiblewith a three-dimensional derivation system, i.e., vector cardiography.Cardiogoniometry, as a first stage of bedside vector cardiography, nowuses a novel and technically simple three-dimensional derivation systemwhich permits the three-dimensional determination of the electricalprocesses at the patient's side. Initially, it only determines themaximum vectors of the QRS loop and the T loop. The information contentof these two quantities is still very large.

It was not previously possible to obtain more complex evaluations ofmeasured values at the bedside. It was conventional practice, forexample as described in U.S. Pat. No. 4,106,495, Kennedy, to collectmeasured data on the body and record these, followed by theirtime-consuming evaluation on a computer. It was not unusual for thepatient to be dead before his data underwent evaluation. Thus, thevirtually direct determination, evaluation and representation of complexrelationships within one or a few heartbeats meets a practical need.On-line evaluation makes it possible to observe the reaction of theheart, for example, on a screen, in the case of medical use on theergometer and with manipulation of all types.

The QRS vector corresponds to the so-called electrical heart axis. Itsposition in space is now qualitatively characterized by the termstransverse or lateral position, steep position, horizontal position,left type, etc. In place of these qualitative terms, cardiogoniometry(KGM) provides a direction which is clearly defined in space. Even minorchanges to this direction can be established in the course of time,e.g., increases or decreases of heat dilatation or hypertrophy, thedevelopment of a left anterior fascicular block, and the like, before itis possible to note any change in the standard electrocardiogram such aswhen measuring according to the prior art. Changes to the QRS vector inthe acute test, such as, for example, the position change of the QRSvector in the left side position, or after stressing or administeringmedications such as, for example, nitroglycerine, make it possible todetect local and small circulation problems in the septal branches ofthe coronary arteries.

Position changes of the T vector give information on the heartrepolarization conditions, i.e., on disturbances of the metabolism orperfusion problems in the myocardium. If there is an ischemia of therear wall (RCA) the T vector is no longer in the standard region and is,instead, positioned further forward. In the case of an ischemia of thefront wall (LCA) it is outside the standard range and further to therear. These changes also appear in the case of local metabolism problemsof the front or rear wall. If the myocardium at rest is stillsufficiently perfused, then the T-vector will probably still have normalvalues. In this case a relative ischemia, that is a latent coronaryinsufficiency may be demonstrated by decreasing the coronary throughput,e.g. by means of nitroglycerine. Nitroglycerine decreases preload aswell as the systolic volume. This results in a lower level of bloodpressure. But nitroglycerine also increases the frequency of the heartbeat. Both effects tend to reduce the flow through the coronaries whichis especially true for slightly contracted ones. As a result of thoseeffects, the T-vector departs from the ischemic myocard position. Thiseffect is sufficiently distinct so that exercising may not be necessary.

The T-vector may drift in a rather limited area if the coronary-stenosisis not total or not complete. The earlier mentioned effect calledfloating can be found by cardiogoniometric measurements on a series ofheart cycles. This effect may be demonstrated e.g. after short heartstops.

Cardiogoniometry may prove very useful for supervision of patientssuffering from heart diseases especially after myocardiac infarctus orpatients submitted to heart surgery, because both vectors react verysensitively to disturbances of the circulation with the heart.

As cardiogoniometry is a non-invasive method lacking of unwantedside-effects it is well adapted to be used for periodic tests of theheart functions and to early detect latent coronary insufficiencies inpatients liable to suffer from myocardial infarctions such as, forexample, smokers, diabetics, managers and hypercholesterolemics. As themethod acts very sensitively and directly to perfusion problems of thecoronary arteries, it should also be suitable for checking heart-activemedications.

As the cardiogoniometer does not merely store the maximum vectors, but,rather, stores both vector loops in toto, it is possible to obtainfurther quantities or magnitudes in off-line processes. Examples arerandom intervals such as tQR_(max) and QR, or tQT_(max) and QT, as wellas the representation of a vector X at time X, e.g., initial vectors. Itis then possible to display these on a screen which applies not only tothe maximum vectors but also to the entire QRS and T loops, eitherindividually or in series for showing, for example, a possible floatingeffect. Thus, an accurate and completely computerized heart diagnosisresults and, as a result of the very small size of the cariogoniometerin accordance with the invention, it is particularly suitable for use inoutpatient departments.

While certain advantageous embodiments have been chosen to illustratethe invention it will be understood by those skilled in the art thatvarious changes and modifications can be made therein without departingfrom the scope of the invention as defined in the appended claims.

What is claimed is:
 1. A method for detecting electrical, heart-relatedsignals in the natural bioelectrical field of a human body comprisingthe steps of:providing apparatus for recording and analyzing electricalsignals, providing a plurality of electrodes, electrically connectingsaid electrodes to said recording and analyzing apparatus; positioning afirst one of the electrodes at point V4 according to Wilson; positioninga second one of the electrodes at point V8 according to Wilson;positioning a third one of the electrodes generally vertically upwardlywith respect to the body above the first electrode with respect to theupright body at a distance equal to the distance between the first andsecond electrodes multiplied by a factor having a value between 0.6 and0.8; positioning a fourth one of the electrodes along a line generallyperpendicular to the line between the first and third electrodes andtoward the right body side therefrom at a distance equal to the distancebetween the first and second electrodes multiplied by a factor having avalue between about 0.6 and 0.8 such that the first, the second and thefourth electrode together define a plane (x,y) of a system of orthogonalaxes (x,y and z), and said plane corresponding in a statistical range toa plane defined by a spatial vector-loop of the healthy heart; andcomputing the electrical signals produced by the electrodes to determineparameters of projections of a spatial vector representing theelectrical field of the heart on at least one of the planes defined bythe axes of said system.
 2. A method according to claim 1 wherein thedistance between the first and third electrodes and the distance betweenthe third and fourth electrodes are both equal to the distance betweenthe first and second electrodes multiplied by 1/√2.
 3. A method forrepresenting the electrical field generated by the heart as a spatialvector defined by coordinates in a system of orthogonal axes whereby theelectrical field produces electrical signals in a plurality ofelectrodes on a human body, comprising the steps of:positioning a firstelectrode at point V4 according to Wilson, positioning a secondelectrode at point V8 according to Wilson, positioning a third electrodesubstantially vertically above the first electrode with respect to theupright body at a distance equal to the distance between the first andsecond electrode multiplied by a factor having a value between 0.6 and0.8, positioning a forth electrode along a line substantiallyperpendicular to the line between the first and third electrode andtoward the right body side therefrom at a distance equal to the distancebetween the first and second electrodes multiplied by a factor having avalue between about 0.6 and 0.8 such that the first, second and fourthelectrode together define a plane of location of the axes of said systemof orthogonal axes, said plane substantially corresponding to a planedefined by a spatial vector-loop of the healthy heart, and computing theelectrical signals produced at the electrodes in order to get parametersof projections of said spatial vector on at least one of the planes ofsaid system of orthogonal axes.
 4. A method for representing theelectrical field generated by the heart of a subject as a spatial vectordefined by coordinates in a system of orthogonal axes whereby theelectrical field produces electrical signals in a plurality ofelectrodes on the subject, comprising the steps of:positioning threeelectrodes on the subject, said electrodes forming a plane containing anarea defined by the projection of the spatial vector while the spatialvector is executing a heart cycle and whereby this area is maximum, andpositioning another electrode outside of said plane and computing valuesof said spatial vector out of electrical signals produced at theelectrodes, said values of said spatial vector corresponding toprojections of said spatial vector in at least one of the planes definedby the locations of said electrodes.
 5. A method according to claim 1 orclaim 4, and the steps of: determining maximum values of the spatialvector, determining timing relations of such maximum values with respectto the beginning of the QRS-wave of the heart cycle, and determining theangle between two of said maximum values of the spatial vector.
 6. Amethod according to claim 1 or claim 4, and the steps of: determiningthe maximum values of the spatial vector, determining timing relationsof such maximum values with respect to the beginning of the QRS-wave ofthe heart cycle, determining both said maximum values and said timingrelations for the QRS-, P- and T-wave of the same heart cycle andcomputing reference values of the maximum vector according to theprinciples of statistics.
 7. A method according to claim 1 or claim 4,and the steps of: determining the maximum values of the spatial vector,determining timing relations of such maximum values with respect to thebeginning of the QRS-wave of the heart cycle, determining both saidmaximum values and said timing relations for the QRS-, P-, and T-wave ofthe same heart cycle, and computing mean values and standard deviationvalues.
 8. A method according to claim 1 or claim 4, and the steps of:determining the maximum values of the spatial vector, determining timingrelations of such maximum values with respect to the beginning of theQRS-wave of the heart cycle, determining both said maximum values andsaid timing relations for the QRS-, P-, and T-wave of the same heartycycle, and establishing a range for normal values of the maximum vectorsin healthy subjects.
 9. A method according to claim 1 or claim 4,wherein said subject is a mammal.
 10. A method according to claim 1 orclaim 4, wherein said subject is a human being.
 11. A method forrepresenting the electrical field generated by the heart as a spatialvector defined by coordinates in a system of orthogonal axes wherein theelectrical field produces electrical signals in a plurality ofelectrodes on a human body containing said heart, comprising the stepsof:positioning a first electrode at point V4 according to Wilson,positioning a second electrode at point V8 according to Wilson,positioning a third electrode substantially vertically above the firstelectrode with respect to the upright body at a distance equal to thedistance between the first and second electrode multiplied by a factorhaving a value between 0.6 and 0.8, positioning a fourth electrode alonga line substantially perpendicular to the line between the first andthird electrode and toward the right body side therefrom at a distanceequal to the distance between the first and second electrodes multipliedby a factor having a value between about 0.6 and 0.8, computingdifferences of the values of the electrical signal measured between eachpair of said electrodes, computing a projection of the spatial vector ofthe electric activity of the heart on planes of a system of axes definedby the locations of the electrodes out of said differences of saidvalues, and transforming said computed projections of the spatial vectorinto projections of the spatial vector within the system of orthogonalaxes, said orthogonal axes defining a plane corresponding to a planedefined by the first, the second and the fourth electrode.
 12. A methodaccording to any one of claims 1-11, and the step of representing thespatial vector during QRS-portions of the heart cycle.
 13. A methodaccording to any one of claims 1-11, and the step of representing thespatial vector during T-portions of the heart cycle.
 14. A methodaccording to any one of claims 1-11, and the step of representing thespatial vector during P-portions of the heart cycle.
 15. A methodaccording to any one of claims 1-11, and the step of measuring theduration of QRS-, T- and P-portions of the heart cycle.
 16. A methodaccording to any one of claim 1-11, and the steps of: determiningmaximum values of the spatial vector, determining timing relations ofsuch maximum values with respect to the beginning of the QRS-wave of theheart cycle,determining both for the QRS-, P- and T-wave of the sameheart cycle.